A Thematic Compendium of Key Studies in Endodontic Outcomes

This document serves as an educational resource designed to distill and

organize the seminal and influential studies in endodontic outcomes. By
structuring this information thematically, from foundational historical
concepts to specific treatment modalities, it aims to create an easy-to-
reference compendium. This framework is intended to facilitate the
learning and memorization of the key evidence that underpins the
principles and practices of modern endodontics, providing clinicians with a
clear, evidence-based foundation for decision-making.

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1.0 Historical and Foundational Studies: The Focal Infection Era

and its Aftermath

Understanding the historical context of endodontics is crucial for

appreciating its evolution into a scientific, evidence-based specialty. The
"focal infection theory," which posited a link between pulpless teeth and
systemic disease, created a significant controversy in the early 20th
century. This challenge, however, spurred the first wave of evidence-
based practice in the field, as diligent practitioners meticulously
documented their work to restore the credibility of endodontic treatment.
This period led to the development of core aseptic principles, the founding
of key organizations, and the establishment of endodontics as a respected
specialty.

Pioneering and Foundational Contributions

Study / Event (Year) Key Finding or Contribution

The Rise of Focal

Infection Theory

Introduced the term "Focus of Infection,"

Miller (1894) highlighting a possible link between "mouth
germs" and systemic disease.

Brought the relationship between oral sepsis

and systemic conditions like bacterial
Hunter (1911)
endocarditis to the attention of medicine and
dentistry.

Hunter (1927) Fears of oral sepsis from deficient root canal

treatment led to widespread extraction of
pulpless teeth, and endodontics virtually
 disappeared from many dental schools.

The Evidence-Based
Response

Advocated for early principles still followed

today: rubber dam isolation, asepsis, microbial
Rhein (1912)
control, and the use of chloro-percha for filling
root canals.

Explored the use of electro-sterilization for root

Prinz (1917)
canals.

Focused on the interpretation of X-rays for

Hinman (1921) differentiating cases favorable for treatment
from those that were not.

Published work on a "practicable root canal

Crane (1921)
technic," emphasizing procedural standards.

Reported on the clinical results of pulp

Blayney (1922) treatments, contributing to the early outcomes
literature.

Investigated pulp-canal opening and filling

Johnston (1923)
through diffusion and electrolytic medication.

Encouraged a more rational approach,

Johnson (1926) advocating for the retention of pulpless teeth
amenable to successful treatment.

Advanced the understanding of pulp canal

Puterbaugh (1926)
therapeutics.

Conducted a prolonged study on the electrolytic

Rhein (1926)
treatment of dental focal infections.

Contributed to the discourse on the "pulpless

Crane (1926)
tooth problem."

Published clinical results from root canal

Coolidge (1927) treatments, adding to the growing body of
evidence.

Appleton & Grossman Assessed and reported treatment outcomes

(1932) using a combination of bacteriological,
 histological, and clinical methods.

Performed one of the first statistical studies of

Buchbinder (1936)
root canal therapy outcomes.

Described a clinical approach to the problem of

Auerbach (1938)
pulp canal therapy.

Formalization of the
Specialty

The American
Association of Marked a pivotal moment in the organization
Endodontists (AAE) is and advancement of the specialty.
founded (1940)

Restoration of The discipline of endodontics was granted

Specialist Status specialist status in the USA, restoring its
(1952) professional reputation.

Modern Echoes of the

Debate

Authored "Focal Infection Revisited," noting that

the better-established science of evidence-
Hughes (1994)
based medicine prevented the same threat as
the original theory.

Highlighted new cost-economic pressures pitting

the decision to "save the tooth" against
Torabinejad (2006)
extraction and replacement with an implant-
supported crown.

The debate over focal infection directly created the need for the rigorous,
factor-based outcome studies detailed in the subsequent sections, which
form the scientific bedrock of modern endodontics.

2.0 Key Studies in Vital Pulp Therapy

The primary goal of vital pulp therapy (VPT) is to manage pulpal

inflammation in a way that preserves the vitality and function of the tooth.
The success of these procedures hinges on careful case selection,
technique, and the choice of materials, with evidence consistently
demonstrating the superiority of MTA over calcium hydroxide.
Consequently, establishing clear clinical and radiographic criteria to
assess outcomes has been a key focus for researchers and professional
bodies, providing clinicians with standardized benchmarks for success.
2.1 Outcome Criteria and Review Guidelines

Source (Year) Summary of Criteria or Recommendation

Success Criteria: <ul><li>Tooth vitality is

maintained.</li><li>Absence of post-treatment signs
The American
or symptoms (sensitivity, pain,
Academy of
swelling).</li><li>Evidence of pulp healing and
Paediatric
reparative dentin formation.</li><li>Absence of
Dentistry
radiographic pathology (resorption, periapical
(2014)
radiolucency, etc.).</li><li>Continued root
development in immature teeth.</li></ul>

Success Criteria: <ul><li>Normal response to pulp

sensitivity tests.</li><li>Absence of pain and other
European symptoms.</li><li>Radiologic evidence of a dentinal
Society of bridge.</li><li>Continued root formation in immature
Endodontology teeth.</li><li>Absence of internal resorption and
(2006) apical periodontitis.</li></ul> Review Frequency:
<ul><li>An initial review at no longer than 6 months,
with regular intervals thereafter.</li></ul>

Recommended Radiologic Review Frequency:

<ul><li>An initial assessment at 6 to 12
Ford (2008)
weeks.</li><li>Follow-up reviews at 6 and 12 months
after treatment.</li></ul>

2.2 Studies on Indirect and Direct Pulp Capping

Study (Year) Key Finding

Indirect Pulp Capping: <ul><li>Similar success rates for

one-step (81.7%) and stepwise (81.9%)
Bjorndal L, approaches.</li><li>Lining material type (e.g., CaOH) did
et al. (2010) not influence the outcome.</li><li>Negative prognostic
factors: older patient age, pre-operative pain, and pulpal
exposure during excavation.</li></ul>

Direct Pulp Capping: <ul><li>Reported a success rate of

Aguilar P, 70.1%.</li><li>Positive prognostic factor: Immature
Linsuwanon roots were associated with significantly more successful
t P (2011) outcomes.</li><li>MTA performed superiorly to calcium
hydroxide (CaOH) as a capping material.</li></ul>

Hilton TJ, et Direct Pulp Capping: <ul><li>Confirmed that Mineral

al. (2013) Trioxide Aggregate (MTA) performed superiorly to calcium
 hydroxide as a capping material.</li></ul>

2.3 Studies on Pulpotomy

Study (Year) Key Finding

Qudeimat MA, et al. Reported success rates of 79.3% for partial

(2007) pulpotomies and 82.4% for full pulpotomies.

Qudeimat MA, et al. Found in randomized trials that MTA achieved

(2007); El-Meligy OA, similar outcomes to calcium hydroxide in both
Avery DR (2006) partial and full pulpotomies.

These studies underscore that while vital pulp therapies can be highly
successful, outcomes are dependent on careful diagnosis and technique.
We now turn to the management of cases where the pulp has become
non-vital, requiring nonsurgical root canal treatment.

3.0 Seminal Studies in Nonsurgical Root Canal Treatment (RCT) &

Retreatment

Nonsurgical root canal treatment is a complex procedure aimed at either

preventing the development of or resolving existing periapical disease. Its
success is not determined by a single action but rather by a complex
interplay of factors. While numerous technical factors have been studied,
the evidence consistently points to the apical extent of debridement and
the quality of the post-operative coronal restoration as the most dominant
influences on periapical healing, while many other factors like material
choice or taper have a surprisingly negligible effect.

3.1 Defining and Measuring Success

Study / Criteria
Description of Criteria
(Year)

A foundational dichotomous framework:

<ul><li>Success: No clinical symptoms, and the
periodontal margin is radiographically normal or only
Strindberg shows widening around excess filling
(1956) material.</li><li>Failure: Presence of clinical
symptoms, or a periradicular radiolucency that is
unchanged, has increased, or has newly
appeared.</li></ul>

Bender et al. Defined success based on: <ul><li>Clinical: Absence of

(1966a, pain, swelling, or fistula; no loss of
1966b) function.</li><li>Radiographic: An eliminated or
 arrested area of rarefaction after 6 months to 2
years.</li></ul>

Introduced the concept of "Functional Retention,"

Friedman defining a successful outcome as the retention of an
(2004) asymptomatic tooth, regardless of the radiographic
presence of a lesion.

Proposed categories to better describe outcomes:

<ul><li>Healed: Asymptomatic with no or minimal
Friedman &
radiographic pathosis.</li><li>Healing: Asymptomatic
Mor (2004)
and functional, but with a reducing radiographic
(Toronto
radiolucency.</li><li>Diseased (Nonhealed):
study)
Symptomatic, or the radiolucency has not changed or has
worsened.</li></ul>

Established outcome criteria including: <ul><li>Healed

The American
– Functional: Asymptomatic with no or minimal
Association of
radiographic pathosis.</li><li>Nonhealed –
Endodontists
Nonfunctional: Symptomatic teeth, with or without
(2005)
radiographic pathosis.</li></ul>

A five-point scale for measuring periapical status that

correlates with histology. It is often dichotomized for
Periapical analysis: <ul><li>Healthy: PAI score of 1 or
Index (PAI) 2.</li><li>Diseased: PAI score of 3 to 5.</li></ul> It
can also classify treatment as Healing (lesion reduced),
Healed (lesion eliminated), or Developing (new lesion).

3.2 Pre-operative Factors Influencing Outcomes

Study (Year) Key Finding Regarding Pre-operative Factors

The bacterial diversity is greater in teeth with larger

Sunqvist (1976)
periapical lesions.

Bystrom, An endodontic infection is more likely to persist in

Sundqvist canals with a higher number of bacteria present pre-
(1981) operatively.

Larger lesions may represent longer-standing infections

Shovelton
with deeper bacterial penetration into dentinal tubules
(1964)
and accessory anatomy.

Nair (2006) Larger lesions carry a greater possibility of

representing a cystic transformation, which can
 complicate healing.

The presence of pre-operative pain is a significant

Friedman S, et
negative prognostic factor, associated with reduced
al. (1995)
success rates.

The presence of pre-operative apical resorption is a

Strindberg LZ
significant negative prognostic factor associated with
(1956)
reduced success.

Ng YL, Mann V,
The presence of pre-operative swelling and/or a sinus
Gulabivala K
tract has a negative impact on periapical healing.
(2011)

3.3 Intra-operative Factors Influencing Outcomes

This section deconstructs the numerous technical factors during the root
canal procedure that have been studied for their impact on treatment
success.

Study / Guideline (Year) Key Finding

Found significantly higher success rates for

Van Nieuwenhuysen
retreatment when a rubber dam was used
JP, et al. (1994)
compared to cotton roll isolation.

Reported a significantly higher success rate for

Goldfein J, et al.
root-treated teeth when a rubber dam was used
(2013)
during post placement.

European Society of States that a principal justification for rubber

Endodontology dam use is medico-legal, to prevent instrument
(2006) ingestion or aspiration.

Study / Guideline
Key Finding
(Year)

The outcome is compromised by canal obstruction

Sjogren U, et al.
or the failure to achieve patency to the canal
(1990)
terminus.

Reported a twofold reduction in the success of

Ng YL, Mann V,
treatment when patency to the canal terminus was
Gulabivala K (2011)
not achieved.

European Society of Recommends extending debridement to the

Endodontology terminus of the canal system (apical constriction,
(2006) or 0.5-2.0 mm from the radiographic apex).

Study / Guideline
Key Finding
(Year)

Concluded that the issue of final apical preparation

Baugh D, Wallace J
size remains controversial despite considerable
(2005)
research.

A randomized trial found that enlargement of the

Saini et al. (2012) canal to three sizes larger than the first apical
binding file (mean final size ISO #30) was adequate.

Hoskinson SE, et Found no significant difference in treatment

al. (2002); Ng YL, outcome between narrow (0.05) and wide (0.10)
et al. (2011) canal tapers.

Study /
Key Finding
Guideline (Year)

Comparing 0.5% to 5.0% sodium hypochlorite (NaOCl),

Bystrom A,
the concentration did not appear to increase the
Sundqvist G
proportion of teeth rendered culture-negative or with
(1985)
greater healing.

Ng YL, Mann Confirmed that NaOCl concentration had a negligible

V, Gulabivala effect but found that the additional use of EDTA had a
K (2011) profound positive effect on periapical healing.

Gulabivala K, Suggested that EDTA may help detach or break up

et al. (2005) biofilms adhering to root canal walls.

Study (Year) Key Finding

Molander A pre-obturation negative culture result may increase

A, et al. treatment success twofold, though sampling is difficult and
(1996) has a low benefit-to-cost ratio.

Fabricius L, A monkey-model study demonstrated that when bacteria

et al. remained after debridement, 79% of canals had non-healed
(2006) lesions, compared to only 28% when no bacteria remained.

Study (Year) Key Finding

Ng YL, et al. Found no evidence that the type of root filling material or
(2008) placement technique has a significant influence on
 outcome. However, the quality and apical extent of the
filling are highly significant.

Confirmed the apical extent of the root filling has a

Ng YL, Mann significant influence. Flush fillings (within 2mm of the
V, Gulabivala apex) were associated with the highest success rates,
K (2011) while long (extruded) fillings were associated with the
lowest.

Study (Year) Key Finding

Ng YL, Mann V, Instrument separation, though having a low prevalence

Gulabivala K (0.5-0.9%), was found to reduce the success rate
(2011) significantly.

In the hands of skilled endodontists, prognosis was not

Spili P, et al.
significantly affected by the presence of a retained
(2005)
fractured instrument.

London An acute exacerbation (flare-up) of pain or swelling

Eastman Study after debridement was found to significantly reduce
(2011) success as measured by periapical healing.

3.4 Post-operative Factors Influencing Outcomes

Key Finding Regarding Post-operative

Study / Guideline (Year)
Factors

An adequate restoration should be placed

The European Society of
after RCT to prevent subsequent bacterial
Endodontology Guidelines
recontamination.

Teeth with satisfactory coronal restorations

The London Eastman had significantly better periapical healing,
Study (2011) highlighting the profound effect of
preventing coronal leakage.

Multiple studies found that the type of

Sjogren U, et al. (1990);
permanent restoration (e.g., crown vs.
Friedman S, et al. (1995);
direct restoration) had no significant
Toronto study (2008); Ng
influence on the outcome of periapical
YL, et al. (2011)
healing.

The placement of a subseal or barrier under

Ng YL, Mann V, Gulabivala
a restoration for additional coronal seal had
K (2011)
no beneficial effect on treatment success.
3.5 Factors Specific to Retreatment

Study
Key Finding
(Year)

Ng YL, et The most significant factor influencing the outcome of

al. (2008, nonsurgical retreatment is the ability to remove or bypass
2010, pre-existing root-filling material or separated instruments to
2011) regain access to the apical portion of the canal system.

While periapical healing is the primary biological goal of RCT, the ultimate
measure of clinical success is whether the tooth can be retained in
function over the long term, a concept known as tooth survival.

4.0 Influential Studies on Tooth Survival Following RCT

There is a critical distinction between periapical healing, a biological

endpoint assessed radiographically, and tooth survival, a long-term
functional outcome measured by retention versus extraction. While a
healed periapex is a strong predictor of survival, the ability to retain a
tooth in function is also heavily influenced by a separate set of factors.
These include systemic health, the structural integrity of the remaining
tooth, the quality of the final restoration, and the occlusal forces it must
withstand.

Study (Year) Key Finding on Tooth Survival

Fouad AF,
Burleson J
Systemic Factors<br><ul><li>Teeth in patients with
(2003);
diabetes or those receiving systemic steroid therapy had
Mindiola MJ, et
a higher chance of being extracted after root canal
al. (2006); Ng
treatment.</li></ul>
YL, et al.
(2011)

Ng YL, Mann Tooth-Related & Pre-operative

V, Gulabivala Factors<br><ul><li>Tooth type had a significant
K (2010, 2011) influence; maxillary premolars and mandibular molars
had the highest frequency of extraction due to
fracture.</li><li>Terminal (last standing) teeth had
lower survival due to unfavorable occlusal
forces.</li><li>The presence of a pre-operative
periapical lesion had no significant influence on tooth
survival.</li><li>The presence of pre-operative
periodontal probing defects, pain, sinus tracts, cervical
resorption, and perforation all significantly reduced
 tooth survival.</li></ul>Treatment
Factors<br><ul><li>The most significant intra-
operative factors reducing tooth survival were a lack of
patency at the apical foramen and the extrusion of
gutta-percha.</li></ul>Restorative
Factors<br><ul><li>The use of cast posts and cores
was found to reduce tooth survival, particularly in
premolars and molars.</li><li>Teeth functioning as
abutments for prostheses had a poorer survival
rate.</li></ul>

Salehrabi R,
Restorative Factors<br><ul><li>Placement of
Rotstein I
crowns or cast restorations was found to significantly
(2004); Ng YL,
improve tooth survival, primarily by helping to prevent
et al. (2010,
root fracture.</li></ul>
2011)

When nonsurgical approaches are insufficient to achieve healing, or when

retreatment is not feasible, periapical surgery becomes the next logical
step in management.

5.0 Pivotal Studies in Periapical Surgery

Periapical surgery is indicated when nonsurgical root canal treatment or

retreatment fails to resolve apical periodontitis, often due to infection that
is inaccessible from within the canal system. Similar to nonsurgical
treatment, surgical success is evaluated against specific radiographic
healing criteria and is influenced by a distinct set of pre-operative and
intra-operative prognostic factors, particularly lesion size and the use of
modern techniques such as magnification and MTA.

5.1 Classification of Surgical Healing

Study
Healing Categories
(Year)

Rud et al. Defined four distinct radiographic healing outcomes following

(1972) apical surgery: <ul><li>Complete Healing: Characterized
and by either complete bone repair (though density may differ
Molven from surrounding bone) or the reformation of a normal or only
et al. slightly widened periodontal ligament space around the
(1987) apex.</li><li>Incomplete Healing (Scar Tissue): The
periapical rarefaction has decreased in size or remained
stationary, with features indicative of a fibrous scar (e.g.,
irregular periphery, asymmetric location around the apex,
angular connection to the periodontal
 space).</li><li>Uncertain Healing: The rarefaction has
decreased in size but still has features suggestive of persistent
inflammation, such as a circular periphery, a size larger than
twice the normal PDL width, or a symmetric, funnel-shaped
extension of the periodontal space.</li><li>Unsatisfactory
Healing (Failure): The rarefaction has enlarged or is
unchanged. A case classified as "Uncertain Healing" at a 4-
year follow-up is also considered a failure.</li></ul>

5.2 Factors Affecting Surgical Outcomes

Study (Year) Key Prognostic Factors Identified

Collective findings from these studies identified several

key factors influencing surgical success: <ul><li>Lesion
Size: Smaller lesions (≤ 5 mm) have a better
prognosis.</li><li>Cortical Plate Involvement:
Lesions involving only one cortical plate have a better
outcome.</li><li>Previous Surgery: The absence of
previous surgery is a positive prognostic
Song M, et al. factor.</li><li>Magnification: Using magnification
(2013); Villa- (e.g., a surgical operating microscope) improves
Machado PA, outcomes.</li><li>Root-End Resection: A minimal
et al. (2013); bevel is associated with better healing than an obvious
Mehta D, et bevel.</li><li>Root-End Preparation: Use of an
al. (2014) ultrasonic tip for retro-cavity preparation is superior to
using a bur.</li><li>Root-End Filling Material: MTA,
SuperEBA, and IRM are associated with significantly
higher success than amalgam.</li><li>Pre-operative
Symptoms: The absence of signs or symptoms is a
favorable factor.</li><li>Periodontal
status</li><li>Quality of the coronal
restoration</li></ul>

This compendium of evidence highlights the scientific foundation of

endodontics and serves as a valuable resource for guiding clinical practice
and supporting ongoing professional development.
An Organized Compendium of Foundational Studies in Endodontic
Outcomes

This document serves as an organized and easy-to-reference guide to the

key studies and research findings that have shaped the modern
understanding of endodontic treatment outcomes. The foundational
research is grouped thematically to facilitate learning and memorization,
covering the historical context that defined the field, the establishment of
objective criteria for success, and the critical prognostic factors that
influence outcomes across various endodontic procedures. By
synthesizing this evidence, clinicians can better appreciate the biological
principles that underpin predictable and successful patient care.

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1.0 Historical Foundations and the Evolution of Endodontic Theory

To fully appreciate modern endodontic practice, it is essential to

understand its historical evolution, which was profoundly shaped by the
"Focal Infection Theory." This theory, which posited a link between
infected teeth and systemic disease, directly influenced clinical practice
for decades, leading to a period of widespread tooth extraction. The
subsequent challenge to this theory, driven by diligent practitioners and
the rise of evidence-based principles, established the foundation for
contemporary tooth conservation and the scientific validation of
endodontic treatment.

 Miller (1894): Introduced the term “Focus of Infection” in his work,

"An Introduction to the Study of the Bacteriopathology of the Dental
Pulp," highlighting a potential link between oral microorganisms and
systemic diseases.

 Hunter (1911): In "The Role of Sepsis and Antisepsis in Medicine,"

brought the apparent relationship between oral sepsis and bacterial
endocarditis to the attention of both the medical and dental
professions.

 Johnson (1926): In response to the growing trend of extractions,

encouraged dentists to adopt a more rational approach, advocating
for the retention of pulpless teeth that were amenable to successful
treatment.

 Hunter (1927): Fears of "fetal oral sepsis" stemming from

inadequately treated root canals, as described in "Chronic Sepsis as
a Cause of Mental Disorder," led to the widespread extraction of
pulpless teeth and a near disappearance of endodontics from many
dental schools.
  The American Association of Endodontists (1940-1952):
Founded in 1940 by diligent practitioners who meticulously recorded
treatment outcomes to demonstrate the effectiveness of root canal
procedures in controlling infection. The AAE was instrumental in
restoring the reputation of endodontics, culminating in the discipline
being granted specialist status in the USA in 1952.

 Hughes (1994): The concept of "Focal Infection Revisited"

emerged but did not pose the same threat as before due to the
establishment of evidence-based medicine and dentistry. The
discussion was instead seen as an opportunity to secure research
funding.

 Torabinejad (2006): Highlighted the new cost-economic pressures

exerted by the rise of dental implants, which forced treatment
planning decisions into a binary choice: "save the tooth" or "extract
it." Evidence-based practice was once again critical in averting
irrational treatment recommendations that favored extraction over
the preservation of savable teeth.

This historical journey from theoretical speculation to scientific validation

underscores the modern necessity for clear, objective criteria to measure
and define treatment success.

2.0 Defining and Measuring Endodontic Success

The development of standardized criteria for evaluating treatment

outcomes is a cornerstone of modern endodontics. These frameworks are
critical for conducting consistent research, enabling clinical auditing, and
facilitating clear communication with patients about treatment prognosis.
They provide the language and metrics to differentiate between a tooth
that has healed, one that is healing, and one that remains diseased.

 Strindberg (1956): Established widely adopted dichotomous

criteria based on clinical and radiographic findings:

o Success: Defined by the absence of clinical symptoms and a

normal radiographic appearance of the periodontal tissues.

o Failure: Defined by the presence of clinical symptoms or the

appearance of a new, unchanged, or enlarging periapical
lesion.

 Friedman & Mor (2004): Proposed alternative terminology from

the Toronto study to provide a more nuanced description of
outcomes and enhance patient communication:
 o Healed: An asymptomatic tooth with a normal radiographic
appearance.

o Healing: An asymptomatic tooth with a radiographically

reduced periapical lesion.

o Diseased: A tooth with clinical signs or symptoms, or a

periapical lesion that has emerged or persisted without
change.

 The American Association of Endodontists (2005): Devised a

five-point scale based on the Periapical Index (PAI) for measuring
periapical status. This system is noted for being accurate,
reproducible, and discriminatory, correlating radiographic findings
with underlying histology.

 Rud et al. (1972) and Molven et al. (1987): Developed a

detailed classification system for assessing the radiographic
outcome of periapical healing following apical surgery:

o Complete Healing: Characterized by the complete

reformation of bone and a normal periodontal ligament space.

o Incomplete Healing (Scar Tissue): A rarefaction has

decreased in size or remained stationary, with characteristics
indicating the formation of scar tissue, such as an irregular
periphery, demarcation by a compact bone border, and an
angular connection between the rarefaction and the
periodontal space.

o Uncertain Healing: A rarefaction has decreased in size but

retains features that make the long-term prognosis unclear,
such as a circular or semicircular periphery, symmetric
location around the apex, and a size larger than twice the
width of the periodontal space. A case still classified as
"uncertain" after four years is considered a failure.

o Unsatisfactory Healing (Failure): A rarefaction has

enlarged or remained unchanged.

These general frameworks provide a basis for assessing treatment

success, with more specific criteria applied to distinct procedures such as
Vital Pulp Therapy.

3.0 Outcomes and Prognostic Factors in Vital Pulp Therapy

Vital Pulp Therapy (VPT) encompasses a range of procedures aimed at

preserving the health and function of the dental pulp. The success of
these treatments is highly dependent on the initial health of the pulp and
a variety of clinical factors. Outcomes are measured by distinct criteria
focused on maintaining vitality and promoting healing.

3.2.1. Indirect Pulp Capping

 Bjorndal L, Reit C, Bruun G, et al. (2010): Identified three

significant negative prognostic factors that reduce the likelihood of
success:

1. Older patient age

2. Presence of pre-operative pain

3. Pulpal exposure occurring during excavation

3.2.2. Direct Pulp Capping

 Aguilar P, Linsuwanont P (2011): Detailed two significant

prognostic factors influencing successful outcomes:

1. Root immaturity: Teeth with immature roots were associated

with significantly higher success rates.

2. Capping material: Mineral Trioxide Aggregate (MTA) was

found to perform superiorly to calcium hydroxide.

 Hilton TJ, Ferracane JL, Mancl L (2013): Further confirmed the

finding that MTA is a superior capping material compared to calcium
hydroxide for direct pulp capping procedures.

3.2.3. Pulpotomy

 Qudeimat MA, Barrieshi-Nusair KM, Owais AI (2007) & El-

Meligy OA, Avery DR (2006): Synthesized findings from
randomized controlled trials revealed that for partial or full
pulpotomies, MTA was a reliable alternative, achieving successful
outcomes statistically similar to those of calcium hydroxide.

3.3 Assessment and Review Protocols for Vital Pulp Therapy

Professional organizations have established guidelines for assessing the

outcomes of VPT to ensure consistent clinical evaluation.

 European Society of Endodontology (2006):

o Key Assessment Criteria: Normal response to pulp

sensitivity tests, absence of pain and symptoms, radiographic
evidence of dentinal bridge formation, continued root
development in immature teeth, and absence of resorption or
apical periodontitis.
 o Recommended Review Frequency: An initial review no
longer than 6 months after treatment, followed by regular
intervals.

 The American Academy of Paediatric Dentistry (2014):

o Key Assessment Criteria: Maintained tooth vitality, absence

of post-treatment signs or symptoms, evidence of pulp healing
and reparative dentin formation, and absence of radiographic
signs of pathology.

 Ford (2008):

o Recommended Radiological Review: An initial assessment

at 6 to 12 weeks, followed by reviews at 6 and 12 months
post-treatment.

While VPT aims to harness the pulp's inherent healing potential, the
management of non-vital teeth shifts the therapeutic focus entirely from
preservation to disinfection, introducing a more complex array of
prognostic factors centered on microbial eradication.

4.0 Key Factors Influencing Nonsurgical Root Canal Treatment

(RCT) Outcomes

Nonsurgical Root Canal Treatment is a multi-stage procedure where

success depends on a complex interplay of patient, tooth, and treatment-
related variables. Decades of research have identified key factors across
the entire treatment continuum—from pre-operative diagnosis to post-
operative restoration—that significantly impact the probability of
periapical healing. This section deconstructs these prognostic factors into
pre-operative, intra-operative, and post-operative categories.

4.2.1. Pre-operative Factors

The condition of the tooth before treatment begins is a powerful predictor

of the final outcome.

 Impact of Periapical Lesions & Infection:

o Sunqvist (1976): Established that the diversity of bacteria is

greater in teeth with larger periapical lesions.

o Bystrom & Sundqvist (1981): Showed that an endodontic

infection is more likely to persist in canals with a higher pre-
operative bacterial load.

o Shovelton (1964): Provided a potential explanation that

larger lesions may represent longer-standing infections that
 have penetrated deeper into dentinal tubules and accessory
canals.

o Nair (2006): Noted that larger lesions also have the potential
for cystic transformation, which can complicate healing.

 Impact of Clinical Signs and Symptoms:

o Friedman S, et al. (1995): Identified pre-operative pain as a

significant prognostic factor associated with reduced success
rates.

o Strindberg LZ (1956): Found that the presence of apical

resorption was a significant factor associated with lower
success rates.

o Ng YL, Mann V, Gulabivala K (2011): Determined that the

pre-operative presence of swelling or a sinus tract has a
negative impact on periapical healing.

4.2.2. Intra-operative (Treatment) Factors

The technical execution of the root canal procedure has a direct bearing
on its biological success.

 Isolation:

o Van Nieuwenhuysen JP, et al. (1994): Found significantly

higher healing rates when a rubber dam was used for isolation
compared to cotton rolls.

o Goldfein J, et al. (2013): Reported a significantly higher

success rate for root canal treated teeth when a rubber dam
was used during subsequent post placement.

 Mechanical Debridement (Patency, Apical Size, and Taper):

o Sjogren U, et al. (1990): Demonstrated that the outcome is

compromised by canal obstruction or the failure to achieve
patency to the canal terminus.

o Ng YL, Mann V, Gulabivala K (2011): Quantified this risk,

reporting a twofold reduction in treatment success when
patency to the canal terminus was not achieved.

o Saini et al. (2012): In a randomized controlled trial, found

that enlargement of the canal to three sizes larger than the
first apical binding file (resulting in a mean final size of ISO
#30) was adequate for success.
 o Hoskinson SE, et al. (2002) & Ng YL, et al. (2011): Found
no significant difference in treatment outcome between
narrow (0.05) and wide (0.10) canal tapers.

 Irrigation and Disinfection:

o Bystrom A, Sundqvist G (1985) & Ng YL, et al. (2011):

Notably, multiple studies have found that the concentration of
sodium hypochlorite (comparing 0.5% to 5.0%) did not
significantly influence the rate of periapical healing,
suggesting that the presence and delivery of the irrigant may
be more critical than its absolute strength.

o Gulabivala K, et al. (2005) & Ng YL, et al. (2011):

Described that EDTA may help detach biofilms and found that
its additional use had a profound effect on improving
radiographically observed periapical healing.

 Microbial Control and Persistent Bacteria:

o Molander A, Reit C, Dahlen G (1996): Stated that a

negative culture result before obturation may increase
treatment success twofold.

o Fabricius L, et al. (2006): In a landmark monkey-model

study, demonstrated the powerful effect of persistent
bacteria. When bacteria remained after debridement, 79% of
canals showed non-healing. When bacteria were detected
after root filling removal, 97% had not healed.

 Obturation (Filling):

o Ng YL, Mann V, Rahbaran S, et al. (2008): Summarized

three key findings related to obturation:

1. The type of root filling material and placement

technique has no significant influence on outcome.

2. The apical extent of the root filling has a significant

influence, with flush fillings associated with the highest
success rates and long fillings the lowest.

3. The radiographic quality of the root filling is highly

significant, with satisfactory fillings yielding much higher
success rates.

 Procedural Complications:
 o Spili P, Parashos P, Messer HH (205): In a case-control
study, found that in the hands of skilled endodontists, the
prognosis was not significantly affected by the presence of a
retained fractured instrument.

o London Eastman Study (2011) / Ng YL, et al. (2011):

Determined that the occurrence of an acute exacerbation
(inter-appointment pain or swelling) was found to significantly
reduce the success of treatment as measured by periapical
healing.

4.2.3. Post-operative Factors

Events following the completion of the root canal filling are critical for
long-term success.

 Coronal Restoration:

o London Eastman Study (2011) / Ng YL, et al. (2011):

Revealed the profound effect of the coronal restoration,
finding that teeth with satisfactory restorations had
significantly better periapical healing than those with
unsatisfactory restorations.

o Sjogren U, et al. (1990); Friedman S, et al. (1995); Ng

YL, et al. (2011): Multiple studies reached a consensus that
the type of permanent restoration (e.g., crown vs. filling) does
not have a significant influence on the outcome of periapical
healing.

 Occlusal Factors:

o Sjogren U, et al. (1990): Noted that root-treated teeth used

as abutments for prostheses may be expected to have lower
success rates, potentially due to fatigue-related cracks and
fractures.

These factors primarily relate to the biological outcome of periapical

healing, which is distinct from the functional outcome of tooth survival.

5.0 Factors Influencing Tooth Survival Following RCT

While periapical healing is a measure of biological success, tooth survival

is a functional outcome that measures whether the tooth is retained in the
mouth or is ultimately extracted. Research shows that a different, though
sometimes overlapping, set of factors influences the long-term functional
success and longevity of an endodontically treated tooth.

 Systemic Patient Factors:

 o Fouad AF, Burleson J (2003); Mindiola MJ, et al. (2006);
Ng YL, et al. (2011): Synthesized findings indicate that
teeth in patients with diabetes had a significantly higher
chance of being extracted after root canal treatment.

 Tooth and Pre-operative Factors:

o Ng YL, Mann V, Gulabivala K (2010, 2011): List the key

findings related to tooth morphologic type, location, and pre-
operative conditions that reduce survival. This includes tooth
type (maxillary premolars and mandibular molars have the
highest extraction frequency), location as a terminal (last
standing) tooth, and the presence of pre-operative pain, sinus
tracts, or perforations.

 Treatment and Restorative Factors:

o Salehrabi R, Rotstein I (2004) & Ng YL, et al. (2010,

2011): Concluded that the placement of a crown after root
canal treatment significantly improves tooth survival, as it
helps prevent root fracture.

o Ng YL, Mann V, Gulabivala K (2010, 2011): Found that the

use of cast posts and cores for retaining restorations was
associated with reduced tooth survival, particularly in
premolars and molars.

o Ng YL, Mann V, Gulabivala K (2011): Reported that teeth

functioning as prosthetic abutments had a poorer survival
rate, likely due to excessive and unfavorable occlusal stresses.

Understanding these factors is essential for comprehensive treatment

planning, which must also consider the potential need for more advanced
procedures like retreatment or surgery if primary treatment fails.

6.0 Outcomes of Advanced Endodontic Procedures

When primary root canal treatment fails to achieve periapical healing,

nonsurgical retreatment or surgical intervention may be required to save
the tooth. These advanced procedures have their own unique success
rates and are influenced by a distinct set of prognostic factors that differ
from those of primary treatment.

 Nonsurgical Retreatment:

o Ng YL, Mann V, Gulabivala K (2008, 2010, 2011):

Identified that the single most significant factor influencing
the outcome of nonsurgical retreatment is the ability to
 remove or bypass pre-existing root-filling material or
separated instruments to regain patency to the apical
terminus of the canal.

 Periapical Surgery:

o Song M, et al. (2013); Villa-Machado PA, et al. (2013);

Mehta D, et al. (2014): A synthesis of findings from multiple
studies reveals several key prognostic factors for surgical
healing:

 Lesion Size: Smaller lesions (≤ 5 mm) have a better

prognosis than larger lesions.

 Cortical Plate Involvement: Lesions involving only

one cortical plate heal better than those involving both.

 Previous Surgery: The absence of previous surgery is

a positive prognostic factor.

 Magnification: Using magnification during surgery

improves the outcome.

 Root-End Resection: A minimum bevel is associated

with better healing than an obvious bevel.

 Retro-Cavity Preparation: Use of an ultrasonic tip is

superior to a bur.

 Retro-Filling Material: MTA, SuperEBA, and IRM are

associated with significantly higher success than
amalgam.

 Clinical Status: The absence of pre-operative signs or

symptoms is a favorable factor.

 Periodontal Status

 Quality of the Coronal Restoration

This compendium of foundational research illustrates a clear and

consistent narrative in endodontic outcomes. While numerous technical
factors, materials, and techniques have been studied over the decades,
the evidence consistently demonstrates that the most powerful influences
are rooted in fundamental biological principles. The success of any
endodontic procedure—from vital pulp therapy to periapical surgery—is
primarily determined by the clinician's ability to achieve and maintain
control of the microbial environment within the root canal system. Equally
important is the long-term integrity of the tooth-restoration complex,
which provides a passive but critical barrier against reinfection.
Ultimately, a deep understanding of these core principles, rather than a
focus on any single technique, is what underpins predictable and lasting
success in endodontics.